PREDICTOR HESSI 05/2018. With All the Answers 100%

1. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client’s blood pressure is cu rrently 142/89. Which ...

1. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client’s blood pressure is cu rrently 142/89. Which interventions should the nurse implement? (Select all that apply) 2. The nurse mixes 250 mg of D5W dobutamine and plans to administer the solution at a rate of 15 mcg/kg/minute to a client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour? (Enter numeric value only rounding is required, round to the nearest whole number) 3. Several days after having a computed tomography scan (CT scan) with contrast for lower abdominal pain, an older male adult is admitted with acute kidney injury (AKI). The client’s urinary output is 10ml/hour, his heart rate is 125 beats/minute, and basilar crackles are audible. Which laboratory value in the client’s electronic record requires intervention by the nurse? 4. A male client is admitted to the hospital with a medical diagnosis of peptic ulcers. The nurse should inform the client that he is most likely to experience the greatest pain and discomforting which situation? 5. 5. A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take? 6. The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team, Which client should the charge nurse assign to the RN? 7. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. 8. A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? 9. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate? 10. A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increasing shortness of breath His arterial blood gas results are pH 7. 22, PaCO, 55 mmHg, HCO, 25 mEq/l or mmol/L. Which intervention should the nurse implement? 11. An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CAV). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) 12. A female client with a history of heart failure (HF) arrives at the clinic after what she describes as a very long trip. Following the initial physical assessment and chart review, which prior action should the nurse implement? (click on each chart for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record) 13. Which information is most important to include in the teaching plan for a client who is discharged after a thyroidectomy for Grave’s disease? 14. The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dl; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D scheduled for an appendectomy who has nurse implement? a white blood cell (WBC) count of 14,000 mm. What intervention should the nurse implement? 15. When administer ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse? 16. An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital the nurse's response should be based on what information? 17. Following a motor vehicle collision (MVC), an unrestrained female client is admitted to the intensive care unit with altered mental status. She has multiple rib fractures and bruising across her lower abdomen. Which assessment finding warrants immediate intervention by the nurse? (Please scroll and view each tab's information in the client's medical record before selecting the answer) 18. An older client comes to the clinic with a family member. When the nurse attempts to take the clients health history, the client does not respond to questions in a clear manner. What action should the nurse implement first? 19. The nurse enters a male client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client. The client is lying in a supine position and his condition has obviously deteriorated. He is weak, pale, and diaphoretic. What is the priority nursing action? 20. A client with syndrome of inappropriate antidiuretic hormone (SIADH) is admitted with a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated pulse rate. Which intervention should the nurse implement first? 21. The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? 22. A male client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client’s admission prescription includes radiation therapy. What action should the nurse implement? 23. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a) . 24. A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? 25. What is the priority nursing problem for a client with hypoparathyroidism? 26. A male client with cirrhosis and severe ascites, who is scheduled for a paracentesis tells the nurse that he is in pain and feels short of breath, so he wants to reschedule the procedure. How should the nurse respond? 27. After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care? 28. A client with chronic renal insufficiency is preparing for discharge from the hospital. Which information is most important for the nurse to include in this client's discharge teaching? 29. The client provides three positive responses to items on the CAGE (cut down, Annoyed, Guilty, Eye-opener) Questionnaire. What interpretation should the nurse provide the client? 30. A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.) a) These medications assist in obstructing client´s vision during the surgery. 31. The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. What action should the nurse take? 32. The healthcare provider prescribes amoxicillin 1.5 grams PO daily, in equaly divided doses to be administered every 8 hours. The medication is available in a bottle labeled “Amoxicillin suspension 200mg/5ml”. How many ml should the nurse administer every 8 hours? (Enter numeric value only. If rounding is required, round to the nearest tenth). 33. The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit what initial symptoms? 34. The nurse is interacting with a female client who is diagnostic with postpartum depression. Which findings should the nurse document as an objective signs of depression? (Select all that apply) 35. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client eat? (Select all that apply.) 36. A client who is hospitalized and recently diagnosed with Addison’s disease is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) 37. After removing a client’s dressing that is saturated with sanguineous drainage, where should the nurse place the dressing? 38. Immediately after extubating, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? 39. The nurse manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? 40. An adult client presents to the clinic with a large draining ulcers on both lower legs that are characteristic of Kaposi´s Sarcoma lesions. The client is accompanied by two family members. What action should the nurse take? 41. Prior to teaching a client how to walk with crutches, which exercises are most important for the nurse to encourage the immobilized client to practice? 42. A female client comes to the emergency center to report that two days ago she was the victim of date rape. Which action is most important for the nurse to implement? 43. An older client is referred to a rehabilitation facility following a cerebrovascular accident is with left-side paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care? 44. The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching? 45. Which client is best to assign to the LPN who is assisting the RN with the care of a group of clients? 46. A confused, older client with Alzheimer’s disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? 47. A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or “goosebumps”. The nurse should asses for which trigger? 48. After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. What action should the nurse take next? 49. The nurse reviews the laboratory results for a client who is admitted with cholelithiasis and identifies the presence of urobilinogen in the urine analysis and elevated serum values for indirect bilirubin, direct bilirubin, and total bilirubin. Based on these findings, which nursing intervention would be considered the priority to include in this client's plan care? 50. A client is to receive mannitol (osmitrol) intravenously for increased intracranial pressure. Which outcome may result from the use of? 51. A young adult client is admitted to the emergency room following a motor vehicle collision. The client’s head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as “Risk of injury”. What term best expresses the “related to” portion of nursing diagnosis? 52. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? 53. A nurse who usually works on step-down unit is moved to work a 12-hour shift in the critical care unit. Which client is best for the charge nurse to assign to this care? 54. The nurse enters a male client’s room to administer oral medications and find an unlicensed assistive personnel (UAP) providing personal care to the client. The client is lying is a supine position and his condition has obviously deteriorated. He is weak, pale, and diaphoretic. What is the priority nurse action? 55. A preeclamptic client who delivered 24 hours ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hours. Her total input is limited to 125 ml per hours, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? 56. The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B with a postoperative hemoglobin of 8.7 mg/ di ;Client C, newly admitted with a potassium level of 3.8 mEq/ L; and Client D, scheduled for an appendectomy who has a white blood cell count of 15.000 mm3. What intervention should the nurse implement? 57. .A client with a new diagnosis of Raynaud´s disease lives alone. Which instruction should the nurse include in this client´s discharge teaching plan? 58. An adult client with a broken femur is transferred to the medical surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client report muscle spasms and pain at the fracture site. While waiting for the client to be transported to surgery, which action should the nurse implement!? 59. A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider’s attention? 60. 61-An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client’s plan of care? (Select all that apply) 61. The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour? 62. An unlicensed assistive personnel UAP leaves the unit without notifying the staff. In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.) 63. 54-A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? 64. A client hospitalized with a fractured mandible is to discharge. Which equipment should the client be instructed to have available at all times? 65. During a Women’s Health Fair, which assignment is best for the practical nurse (PN) who is working with a registered nurse (RN)? 66. The nurse notes that an older adult client has a moist cough that increase in severity during and after meals. Based on this finding, what action should the nurse take. 67. The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate 15mcg/kg/minute a client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.) 68. A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 69. A client in the third trimester of pregnancy reports that she feels some “lumpy places “ in her breast and that her nipples sometimes leak yellowish fluid. She has an appointment with her healthcare provider I two weeks. What action should the nurse take? 70. An older adult client admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) 71. An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way food is prepared in the hospital the nurse’s response should be based on what information? 72. The nurse is preparing a client with as acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life threatening and should be reported to the healthcare provider immediately? 73. 66-A client who is at 10-weeks’ gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determined that the client has no fever. Which instruction should the nurse give this client? 74. The nurse should expect a client diagnosis with regional enteritis (Crohn’s disease) to exhibit what initial symptoms? 75. An unresponsive male victim of a diving accident is brought to the emergency department where it is determining that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. What action should the nurse take first. 76. A 300 ml unit of packed red blood cells is prescribed for a client with heart failure (HF) who has 3+ pitting edema, shortness of breath with any activity, and crackles in both lung bases. What rate should the nurse administer the blood? 77. An older female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms? 78. The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/ minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant’s plan of care? 79. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? 80. The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? 81. An adolescent girl with anorexia nervosa is within 10 pounds of her normal weight and is being discharge from the mental health unit with a prescription for fluoxetine (prozac). Which instruction is most important for the nurse to provide the parent listen for the daughter expressions of wanting to harm herself 82. A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? 83. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client’s discharge plan? (Select all that apply). 84. Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client’s dressing. Which additional assessment finding warrants immediate intervention by the nurse. 85. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? 86. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take? 87. The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. What is the priority nursing intervention based on the client´s current GCS? 88. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? 89. A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? 90. A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? 91. A 13 years-old girl, diagnosed with DM Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? 92. What instruction should the nurse provide to a client who is preparing to have a cystoscopy? 93. On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain? 94. A nurse that she is concerned about her 81 – year old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive, but is occasionally seen walking outside wearing only robe and slippers. What response should the nurse offer? 95. While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client’s laboratory values? . 96. While changing a client’s chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? 97. Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client? 98. A small, round raised are appears under the client’s skin as the nurse administers an intradermal medication. What actions should the nurse take? 99. The nurse instructs UAP to turn an immobilized elderly client with an indwelling urinary catheter every two hour. What additional action should the nurse instruct the UAP to take each time the client is turned? 100. A heparin infusion is prescribed for a client who weighs 220 pounds after administering a bolus dose of 80 units/kg. The nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour. 18 101. At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client’s medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation: 102. A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? 103. The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch the toes. Which finding indicates a student should be referred for scoliosis evaluation? 104. Which client should the nurse assess frequently for risk of overflow incontinence? 105. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? 106. The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? 107. A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff’s sign). Which pathophysiological mechanism supports this response? 108. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location) 109. Which intervention should the nurse include in the plan of care for a child with tetanus? 110. A client with leukemia undergoes a bone marrow biopsy. The client’s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? 111. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? 112. The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse’s proposal? 113. An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition? 114. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm? 115. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? Rationale: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and self-administer a dose of regular insulin per sliding scale. 116. An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? Rationale: Trousseau’s sign is indicated by spasms in the distal portion of an extremity that is being used to measure blood pressure and is caused by hypocalcemia (normal level 9.0-10.5 mg/dl, so C should be implemented 117. A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client’s discharge teaching plan? 118. The nurse notes a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? 119. The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes? 120. An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)? 121. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? 122. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? 123. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? 124. Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply) 125. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory values requires intervention by the nurse? 126. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider? 127. After receiving report, the nurse can most safely plan to assess which client last? The client with… 128. A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client’s therapeutic response to this medication, which assessment should the nurse obtain? 129. A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take? 130. The nurse is teaching a male adolescent recently diagnosed with type 1diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching? 131. Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client’s response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom) 132. When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include? 133. A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important? 134. The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider? 135. The nurse asks the parent to stay during the examination of a male toddler’s genital area. Which intervention should the nurse implement? 136. An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar in addition to the client’s glucose, which laboratory value is most important for the nurse to monitor? 137. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? 138. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? 139. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? 140. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image). 141. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? 142. A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? 143. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day and has also experiences a loss of appetite. What instruction should the nurse provide? 144. While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? 145. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? 146. The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is 147. The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? 148. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? 149. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today? 150. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hour. What additional action should the nurse instruct the UAP to take each time the client is turned? 151. A female client who was mechanically ventilated for 7 days is extubated. Two hours later…productive cough, and her respirations are rapids and shallow. Which intervention is most important? 152. The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? 153. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? 154. In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition? 155. The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer’s disease. What action should the nurse take? 156. An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? 157. A client with Addison’s disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client’s laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? 158. A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? 159. When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? 160. A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? 161. The nurse applies a blood pressure cuff around a client’s left thigh. To measure the client’s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.) 162. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? 163. A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply) 164. A 17-year –old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? 165. A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? 166. The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. which client with which change in status is best to assign to the PN? 167. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? 168. A nurse working on an endocrine unit should see which client first? 169. The nurse is caring for a group of a clients on a surgical unit. Which client should the nurse assess first? 170. A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide? 171. What intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an IV site in the client's arm? 172. When obtaining subjective data from a client, what intervention should the nurse implement first? 173. When implementing a disaster intervention plan, which intervention should the nurse implement first? 174. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? 175. When preparing a client for discharge from the hospital following a cystectomy and urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client´s discharge teaching plan? 176. The nurse is preparing to send a client cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to start of the procedure? 177. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self –centered, angry person I have ever met. If the loses his temper one more time with me, I am going to punch him out’’ The nurse recognizes that the client is using which defense mechanism? 178. Which instruction is most important for the nurse to provide a client who receives a new prescription for risedronate sodium to treat osteoporosis 179. A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase? 180. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow frequent dribbling after voiding and increasing nocturia with difficulty initiating his urine stream action should the nurse implement? 181. A client with pneumonia has arterial blood gases levels at: pH 7.33; PaC02 49 mm/ Hg; HC03 25mEq/L; PaO2 95. What intervention should the nurse implement based on these results? 182. What is the primary purpose for initiating nursing intervention that promote good nutrition, rest, and exercise, and stress reduction for clients diagnosed with an HIV infection? 183. After diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions? 184. Which laboratory results should the nurse closely monitor in a client who has end – stage renal disease (ESRD) 185. A client who is admitted to the medical unit with fluid volume overload has 2+ dependent edema in the lower extremities and a serum sodium level of 115mEq/L. Which assessment should the nurse complete next? 203- A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. When breakfast items should the nurse encourage the client to eat? (Select all that apply) 204- After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply) 205- A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement? 206- A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective? 207- The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long- term control of diabetes? 208- The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first? 209- The nurse assesses an older adult who is newly admitted to a long-term care facility. The client has dry, flaky skin and long thickened fingernails. The clients have a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)? 210- A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hr? (Enter numeric value only. If rounding to the nearest whole number.) 45 211- The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique? (Arrange from first action on top to last action on bottom) Remove old dressing using clean gloves. Discard gloves with old dressing Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area” Apply sterile gauze dressing to wound area Secure dressing with tape 212- The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speaker together in the foreign language for an additional 2 minutes until the interpreter concludes, “She says it is OK.” What action should the nurse take next? 214- After receiving report, the nurse can most safely plan to assess with client last? 215- The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance? 216- A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? 218- After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, “God has abandoned me. What did I do to deserve this?” Based on this response, the nurse decides to include which nursing problem in the client’s plan of care? 219- Un infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse? Brachial pulse Infant <1 year old, brachial pulse 220- A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which action should be taken? (Select all that apply) 221- The mother of a school age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse best response? (nits liendra) 222- When assessing a client with acute asthma, the nurse is most likely to obtain which finding? 223- A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care? 225- Which intervention should the nurse include in the plan of care for a patient with tetanus? Open window shades to provide natural light 226- A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.) 227- A client collapses while showering and is found discovered by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next? 228- A female client with cancer tells the home care nurse that she has a good appetite but experiences nausea whenever she smells food cooking. What action should the nurse implement? 229- At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, which priority nursing action should the nurse implement? Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record. 230- Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first? 231- After a motor vehicle collision a client admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement? 232- The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement? 233- The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately? 234- A male client with diabetes mellitus takes NPH/ regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the azithromycin an hour before breakfast as instructed. What action should the nurse implement? 235- After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? 238- A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first? 239- The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement? 240- A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement? 241- A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? 242- A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the las 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescriptions has the highest priority? 243- A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care? 245- A preschool teacher notifies the school nurse that child A has bitten child B on the arm. Child B’s skin is broken, but is not bleeding. What action should the school nurse take first? 246- At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? 247- Prior to surgery, written consent must be obtained. What is the nurse’s legal responsibility with regard to obtaining written consent? 248- The nurse provides sliding scale insulin administration instruction to an adult who was recently diagnose with diabetes mellitus. The client demonstrates and understanding on the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.) Obtain blood glucose level Verify the insulin prescription Draw insulin into insulin syringe Cleanse the selected site 249- What is the primary focus of postoperative nursing care for the client with colon trauma? 250- While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first? 251- A client who is mechanically ventilated is receiving continuous enteral feedings through a nasogastric feeding tube. To prevent aspiration, which intervention is most important for the nurse to implement? 252- After years of struggling with weight management, a middle-age man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client’s plan of care? 253- After receiving report on an inpatient acute care unit, which client should the nurse assess first? 254- An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay? 255- A client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take? 256- A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement? 257- When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client’s plan of care? 258- An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care? 259- The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube? 260- The urinary drainage of a client with a continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement? 261- The nurse is preparing to administer a suspension ampicillin labeled, 250mg/5ml, to a 12-year old child with impetigo. The prescription is for 500 mg QID. How many ml should the child receive per day? (Enter numeric value only) 40 262- A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first? 263- The nurse receives report on four clients who are complaining of increased pain. Which client requires immediate by the nurse? 264- A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for nurse to include the in this client’s plan of care? 265- A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the clients begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, ‘’ My favorite nurse is on duty now” Which response is best for the nurse to provide to this client’s dichotomous tendency? 266- The nurse is calculating the one-minute Apgar score for a newborn male infant, and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant? (Enter the numeric value only.) 8 268- In preparing a nursing care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority? 269- A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? 270- What Nursing intervention is particularly indicated for the second stage of labor? 271- An adult male with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client’s blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse? 272- A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care? 273- The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem? 274- A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse? 275- A client with prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement? 277- A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client? 278- A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply) 279- An older male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions the client is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has a foul odor. These findings suggest that this client is experiencing which condition? 280- While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s serum laboratory values? 281- A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all apply) 282- The nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client expresses understanding about when, how, and why to take his prescribed medications at home. Which intervention is most important for the nurse to implement 283- The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? 284- An IV infusing in a client’s left forearm becomes infiltrated. After removing the IV, which sites should the nurse select as possible site to insert another IV catheter? (Select all that apply) 285- A client has had several episodes of clear, watery diarrhea that starter yesterday. What action should the nurse implement? 287- A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client? 288- A nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client complains of paresthesia in the fingers and toes. Which serum laboratory finding should the nurse expect to find? 289- The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? 290- In performing the admission assessment for a client experiencing complications of long term Parkinson’s disease, which question by the nurse provides the best information about disease 291- An adult suffered burns to face and chest resulting from a grease fire. On admission, the client was intubated and a 2 liter bolus of normal saline was administered IV. Currently the normal saline is infusing at 250ml/hour. The client’s heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP)is 4 mm H2O. Which intervention should the nurse implement? 292- The nurse is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to include in this client’s plan of care? 293- After successful resuscitation, a client is given propranolol and transferred to Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5 W at one gram/hour. Which assessment findings require immediate intervention by the nurse? 294- A woman at 12-week gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit? 295- A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply) 296- The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago the nurse notes that the dressing on the client’s right knee is saturated with serosanguineous drainage. What action should the nurse implement? 297- An older adult with known cognitive impairment residing in a long- term care facility suddenly becomes disoriented and confused. There are no signs of extremity weakness or other neurological changes. Which intervention should the nurse implement? 298- After receiving the morning report at 0700 on a postpartum unit, which client should the nurse assess first? The client who is 299- The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client’s room after taking vital signs. What action should the nurse take? 300- Which client problem has the higher priority for the child sickle cell anemia who has a temperature of 101 F (38.3)? 301- A client with chronic kidney disease receives a prescriptions for darbepoetin alfa 40 mcg subcutaneous every 7 days. The darbepoetin alfa vial is labeled, “60 mcg/ml” How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth) 0.7 302- A client with metastatic cancer who was taking hydromorphone (Dilaudid) PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the Dilaudid, what assessment should the nurse complete? 304- While transferring a client with a chest tube from the bed to a stretcher, the chest becomes disconnected from the water-seal drainage container. The nurse immediately immerses the end of the tube in a container of sterile water. What action should the nurse implement next? 305- The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider? 306- A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care? 307- The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet? 308- What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? 309- A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent? 310- A lethargic one-hour-old infant is brought to the nursery for further assessment. In what order should the nurse assess this infant? ( Arrange the first on the top, and the last item on the bottom) Heel stick Respirations Heart rate Temperature 311- When washing soiled hands the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top to last action on botton.) RESPONDIDA Rub hands palm to palm Interlace the fingers Dry hands with paper towel turn off water faucet 312- The nurse changes a Pleuravac® chest drainage system for a client whose chest collection unit is filled to capacity. After unclamping the attached chest tube, the nurse turns on the suction to 20 cm water pressure, and 125 ml of serosanguineous drainage is obtained. Which location on the Pleuravac® indicates this volume of drainage from the chest tube? (Click the chosen location. 313- A client with a pneumothorax is admitted for insertion of a chest tube that is attached to suction with a chest drainage system. The nurse verifies that the suction level is at 20 cm water pressure. Which location on the chest drainage system indicates this finding? 314. An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? 315- A young adult male who was in a motorcycle collision experienced a laceration of the gastrocnemius muscle. Which instruction should the nurse to provide to the practical nurse (PN) who is caring for this client? 316- A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? 317- In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths / minute. What action should the nurse implement? 318- At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? 317- The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? 318- After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? 319. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? 321. The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client? 322. During the administration of albuterol per nebulizer, the client complains of shakiness. The client´s vital signs are heart rate 120 beats/minutes, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take? 323. A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? 324. One week after an above-the-knee-amputation (AKA) of the left leg, a male client seems upset and reports that his left foot feels “numb”. What action should the nurse implement? 325. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include? 326. A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child’s hernia. Which explanations should the nurse provide? 327. A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? 328. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? 329. The nurse assesses a child in 90-90 traction. Where should did nurse assess for signs of compartment syndrome? 330. A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed? 331. When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has 332. A client has both primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to determine the current rate of infusion of the primary IV. Where should the nurse observe to determine the rate of infusion? 333. During a visit to the Planned Parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for Chlamydia six months ago, which factor in this client’s history poses the greatest risk for this woman’s pregnancy? 334. A client is being treated for syndrome of inappropriate ant diuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first? 335. Oxygen at 5l/min per nasal cannula is being administered to a 10-year-old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? 336. A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide? 337. In assessing a client twelve hour following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? 338. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? 339- An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA) The client is aphasic with left-side paresis and having difficulty swallowing. Which intervention is most important for the include in the client pan of care 340-A client who is admitted with palpitations. Chest discomfort and shortness of breath is anxious while reporting a history of a mitral stenosis related to rheumatic fever as a child. The cardiac monitor displays a supraventricular tachycardia (SVT) at a rate of 180 beats/minute. Vital signs include heart rate 156 beats/minute, respiration 22 breaths /minute, and blood pressure 100/84. Which intervention should the nurse implements first? 341. To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement? 342. When administering ceftriaxone sodium (Rocephin) intravenously to a client before…most immediate intervention by the nurse? 343. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective sign of depression? (Select all that apply) 344- A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: 345. An adult woman who has a history of interior myocardial infarction, esophageal reflux, and type 1 diabetes mellitus (DM) is admitted to the telemetry unit for sudden onset of dizziness with palpation and a burning sensation in her chest. Witch interventions should the nurse implement first? a. 346- An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week “I’m trying to start a new business and “I’m too busy to eat”. The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? 347- A male client who was discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, and swollen left. The nurse is preparing to initiate heparin therapy. What additional intervention should the nurse include in this client plan of care? 348- The nurse is teaching a group of women about osteoporosis and exercises. The nurse should emphasize the need for which type of regular activity. 349- The mother of an adolescent female tells the clinic nurse that after every meal her daughter goes to the bathroom, looks the door, and vomits. Which physical assessment should the nurse implement if bulimia is suspect? 350- A client who has a herniated intervertebral lumbar disc is experiencing severe pain in the right leg. What pathophysiological process explains this client’s pain? 351- The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? 352. A neonate whose mother used cocaine during pregnancy is demonstrating extreme irritability, a shrill cry and frequent vomiting. What action should the nurse perform first? 353. An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. What action should the nurse take first. 354- When assessing a multigravida, the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? 355. A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which interdisciplinary team member should the nurse consult to assist the client? 356. A client with hemorrhoids ask for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (select all that a apply) 357. The nurse is monitoring a client who is newly diagnosed with adrenal insufficiency. The client expresses chronic fatigue and requires assistance to the bathroom. The client is anxious about having a chronic disease that could affect the ability to work. Which intervention should the nurse implement Firs.? 358- A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? 359- An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In what order should the unit manager implement these interventions to address the UAP’s behavior? (Place the actions in order from first on top to last on bottom). 364.. The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement? . 360- The charge nurse in a critical care unit is reviewing clients’ conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? 366-. A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? 367- An older male client with type 2 diabetes reports that he experiences leg pain when walking short distances, and that the pain is relieved by the rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? 368- The nurse is assessing the skin of a client who is at risk for becoming infected with the human immunodeficiency virus (HIV). Which finding requires immediate intervention? 369- Which conditions are most likely to respond to treatment with antihistamines? (select all that apply.) 370. The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client? 371. A male client with a history of heavy alcohol intake is admitted with acute pancreatitis. The client reports severe abdominal pain, radiating to the back. In positioning the client, which instruction should the nurse provide the unlicensed assistive personnel (UAP)? 372. The healthcare provider prescribed furosemide for a 4-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was 373. A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/ dl (15g/L). Which intervention is the priority for the nurse to implement? 374. The nurse is assessing the feet of a client with diabetes mellitus type 1. Which finding requires the most immediate intervention by the nurse? 375- A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin initiated. In what order the nurse implement these interventions? (Arrange the action in order of priority. Highest priority first and least priority las tor at the bottom) 376- The healthcare provider prescribes amoxicillin 1.5. grams PO daily, in equally divided doses to be administered every 8 hours. The medication is available in a bottle labeled. “Amoxicillin suspension 200 mg/ 5 ml.” How many ml should the nurse administer every 8 hours? (Enter numeric value only. If rounding is required, round to the nearest tenth.) 37.5 377- A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention? Maintain contact transmission precautions 379. In assessing a client at 34-weeks’ gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? 380. A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next? 381. The school nurse is screening students for scoliosis and notes that one student has lordosis. Which finding should the nurse document in the student’s screening record? 382. A client’s subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? 383 The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? 384. An adolescent client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse implement next? 387. The nurse planning group therapy for client in a substance abuse program. The focus of the group is “Risk factor hepatitis” What intervention should the nurse plan for the group? 388. The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drug, indicates a need to closely monitor the client for toxicity? 389. When developing a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA) which action should the nurse instruct the client to implement if this sign of DKA occurs? 390. A client with cirrhosis of the liver is having numerous, liquid, incontinent stool, and continues to be confused. In reviewing the client’s laboratory studies, the nurse identifies an elevated serum ammonia level. Based in this finding. Which prescription is most important for this client to receive? 391. A client with asthma is manifesting inspiratory and expiratory wheezes and decreased forced expiratory volume. Which prescribed drug class should the nurse administer first to the client? . 392. The nurse is taking the blood pressure measurement of a client with Parkinson disease. Which information in the client’s admission assessment is relevant to the nurse plan to taking the blood pressure reading (select all that apply) 393. In formulating the nursing care plan for a client diagnosed with Parkinson’s disease, which nursing problem has the highest priority? 394. A female adolescent client admitted to the hospital because she wrote a suicide note to her teacher at school. On the second day of hospitalization, the with the treatment team. After the team meeting, the client leaves in tears and hoes to her room. Which nursing intervention is best? 395. The nurse takes the morning vital signs of an older resident at a long-term care facility. Vital signs are: temperature 98.7 F (37 C) pulse 84beats/minute, BP 86/64. Which question is most important for the nurse to include in the assessment 396. When reviewing the discharge plan with a client who has difficulty hearing. The client asks the nurse to repeat the information several times. What action is most important for the nurse to take to ensure the client is receiving and understanding the teaching? 397-A client who is hospitalized and recently is now confused and lethargic. Which actions should the nurse implement? (Select all that apply) 398-The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client? 399- To prevent medication errors by an older client who is sometimes confused, which intervention by the by the home a) A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide? Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? Use two forms of contraception while taking this drug. An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms? Destruction of joint cartilage. Amputation phantom limb= cause and nature of this sensations to reinforce preoperative teaching 602- A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement? 603- A client with Addison’s crisis is admitted for treatment with adrenal cortical supplementation. Based on the client’s admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) 604- A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client’s plan of care? 605- The nurse enters a client’s room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first? 606- During a clinic visit, a client with a kidney transplant ask, “What will happen if chronic rejection develops?” which response is best for the nurse to provide? 607- The nurse enters a client’s room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first? 608- A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? 609- A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication? 610- A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste “bitter”. He complains that he simply has no appetite. What action should the nurse implement? 611- A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make? 612- Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.) 613- Methylprednisolone (Solu-Medrol) 100 mg IV is prescribed for a client. The medication comes in a vial labeled “125 mg per ml” How many ml should the nurse administer. (enter numeric value only. If rounding is required, round to the nearest tenth) 0.8 ml 614- An adult woman who has a history of inferior myocardial infarction, esophageal reflux, and type 1 diabetes mellitus (DM) is admitted to the telemetry unit for sudden onset of dizziness with palpitations and burning sensation in her chest. Which intervention should the nurse implement first? 615- A client with Huntington’s disease is exhibiting choreic movements. Which action the nurse implement first? 616- A client who is in labor tells the nurse: “I just felt a large gush of water- I think my water broke”. After assessing the FHR of 140 beats per minute, which action should the nurse implement next? 617- A client’s cardiac monitor displays new prominent U waves. What action should the nurse implement? Select all that apply. 618- A female client experiencing her four episode of heart failure insist that she has followed a strict diet and taken her prescribe medications. What intervention is most important to for the nurse to include in the client’s discharge teaching plan? 619- A female client with vomiting and diarrhea for the past 2 days arrives in the fast-track clinic complaining of thirst but is… tolerate oral fluid at this time. Her blood pressure is 110/70 with heart rate of 80 beats/minute, and her standing blood pressure is 90/60 with a heart rate of 120 beats/minute. Which action is most important for the nurse to take? 620- The nurse observes a UAP begin to removes exam gloves after emptying a bedpan containing feces. The UAP slides two fingers inside one of the gloves and begins to roll the glove off. What action should the nurse implement? . 621- An adult woman who has recently diagnosed with type 2 diabetes mellitus (DM) is seen in the clinic for laboratory test. The client height is 5 feet and 2 inches (152.5 cm) and weight is 165 pounds (74.8kg). Her recent laboratory finding are describe above. IN planning nutrition. Her recent laboratory finding are described above. In planning nutrition teaching for this client, what diet modifications should the nurse recommend? Select all that apply. 622- An experiences UAP is hired to work with in an antepartal clinic. Which assignments is best for this new employee’s first day of work at the clinic? 623- The home health nurse assesses a male client who is on the waiting list for a liver transplant. The client expresses fear that he will die before a liver becomes available. How should the nurse respond? 624- The healthcare provider prescribes a low dose heparin protocol at 18 units/kg/hr. for a client with a possible pulmonary embolism. This client weighs 144 pound. The available solution is labeled, Heparin Sodium 25,000 Units in 5% dextrose… 250ml. The nurse should program the pump to deliver how many m/hr. (enter numeric value only. If round to the 625- The nurse is planning care for a client at 30-weeks gestation who is experiencing…. Most important in preventing this fetus from developing respiratory distress syndrome… 626- The nurse places one hand above the symphysis while massaging the fundus of a multiparous… 15 mints after delivering a 7 pound and 10 ounces’ infant. Which information should the nurse pr